Representatives from the GHEC-CUGH Education Transition Committee hosted this session to report on progress toward defining the education mission of the GHEC-CUGH partnership and to solicit input from participants on education priorities. The committee was formed to prepare recommendations on the goals and scope of education activities, core competencies (specifically in the areas of undergraduate education, law, environmental science and business), activities that would link education to service and research, integration and continued development of existing GHEC materials, and the scope of the student advisory council.

After distributing a document highlighting the accomplishments and products of GHEC, the presenters shared the charge of the transition committee and its recommendations, which will be available on the GHEC web site. During the discussion period, participants addressed both the regional and topical scope of “global health education” and debated to what extent global health education should include non-medical, non-clinical, and “non-health” fields. Some participants felt that global health education should take a more inclusive and comprehensive approach, involving business, law, anthropology, economics, etc.; others discussed global health education more in terms of medicine, public health, veterinary sciences, dentistry, nursing, etc. One of the panelists noted that the CUGH and GHEC are comprised overwhelmingly of individuals and institutions associated with medicine and that disciplinary diversification should be a priority.

(Note: the CUGH recently added three new members to its board, from the disciplines of law, engineering, and veterinary medicine.) The Education Transition Committee continues to solicit input on the educational priorities of GHEC-CUGH.

Eighty-eight percent of the women who die from cervical cancer and sixty-three percent of the women who die from breast cancer live in low or middle-income countries. These are the staggering statistics presented today by Dr. Felicia Knaul, associate professor at Harvard Medical School. Dr. Knaul, a breast cancer survivor herself, is working to bridge the divide in cancer care between developed and developing nations. While cancer knows no economic boundary, people living in poor areas are disproportionately suffering from treatable and preventable cancers.

In addition to disparities in treatment and prevention, Dr. Knaul also addressed the fact that pain control or palliative care is almost nonexistence in many LMICs. In her work to expand access to cancer care in developing countries, Dr. Knaul proposes a “Diagonal” approach to setting priorities and addressing gaps in the health system.

Dr. Knaul also states that not only is expanding cancer care in developing countries necessary and appropriate, it is also predicted to be cost-effective. Broad estimates suggest that increases in cancer care could lead to 130-850 billion dollars worldwide. At the end of her engaging and thought provoking presentation, Dr.

Knaul reminded us all that cancer care is not about the disease, but it is about people and that this is what we need to remember when moving forward with global cancer care and research.

Several speakers participated in the session “Ethics and Global Health Research” on Monday afternoon. The session was moderated by Ibrahim Daibes, of the Global Health Research Initiative. The speakers highlighted that ethics in global health research goes far beyond what many traditionally think of as “research ethics” – such as getting approval from a research ethics board, getting informed consent statements, and so on. The issue is much more wide-ranging.

“There are various ’ethical stops’ in the knowledge-to-action cycle of global health research where one can pause and reflect,” said Kristiann Allen, of the Canadian Institute for Health Research (CIHR).

The speakers discussed various ethical questions that can be explored during the research process, including:

– To what extent does your discipline or theoretical perspective influence the research agenda?

– Are you conducting research because you are “following the money” (the priorities of funders)? Is it the most relevant research?

– How do you choose collaborators?

– How do you ensure that there is an ethical partnership in the case of collaboration between researchers from the North and the South? What are the power dynamics?

– In the process of knowledge translation, what information is ‘privileged’?

– What are the ethics of sustainability? What will happen once the project finishes?

– What is the best way to handle ethical issues related to knowledge ownership? “What if a government official want to have his name appear on the study, but he did nothing?” asked Martin Forde.

Erica Di Ruggiero of CIHR raised some important questions concerning the role of funders in determining the research agenda and the extent to which various forces influence the priorities of funders. “Why do funders allocate resources to some issues and not to others?” she asked. She added that, “funders have to look at the ethical implications of their decisions and where they put their dollars – ultimately it’s a resource allocation issue.”

Susan Tilley ofBrockUniversity encouraged researchers to explore the extent to which the “sociocultural identities that we carry influence the research process.” She asked, “what preparation is necessary to ensure that we conduct respectful research?”

Karin Morrison said that there are, “a complex network of moral relationships that change over time as we pass through the research process.” She emphasized that, “there are techniques and tools that can be applied to navigate challenges and come to a resolution.”

The session was very positively received, and generated a number of questions and comments, as well as the sharing of personal experiences and challenges, from audience members.

Dr. Roger Glass, Director of the Fogarty International Center (FIC) at the US National Institutes of Health (NIH), outlined opportunities for training and research in global health as envisioned by NIH and by FIC and its international collaborators. Glass highlighted sample FIC programs and partnerships, including those with universities, with other NIH centers and institutes, with the private sector, and with the governments of other countries.

Glass stressed the importance of providing young scientists with substantive, innovative and well-mentored research opportunities early in their career, comparing those experiences to “early childhood education.” To reinforce his point, Glass presented a slide showing the career trajectories of early participants in the AIDS International Training and Research Program (AITRP) that was established by FIC in 1988 to train scientists in developing countries to address the AIDS epidemic. He noted that each of the trainees had gone on to successful and impactful careers in HIV/AIDS research and policy and, notably, they all had returned to work from within their country of origin. “These people represent sustainable research in the developing world,” Glass said. Dr. David Serwadda, Professor of Public Health at Makerere University in Uganda, who is in attendance at the Montreal conference was one of the early AITRP trainees featured on the slide. Glass underscored the importance of these sustained relationships with and between researchers all over the world noting that those relationships “build the bridges between those with eyes in the sky and those with their feet on the ground.”

In keeping with his early childhood education and “lifespan” theme, Glass noted that most of the US-based leaders in global health were early beneficiaries of FIC programs. He also noted that they all are “old white men” who were trained as infectious disease physicians. He then projected a slide showing “Tomorrow’s Leaders in Global Health,” a smiling group of young FIC-supported men and women from all over the world addressing global health challenges from multiple cultural and disciplinary perspectives.

Glass described NIH’s burgeoning partnerships with the BRIC (Brazil, Russia, India, and China) countries and presented specific funding programs that were jointly developed by NIH with the Indian and Chinese governments, both of which have been increasing investments in health research. Glass described these collaborative programs as a “way to get twice the results with half the cost and at a quicker speed.”

In addition to promoting and supporting global partnerships, FIC is promoting the exploration of emerging technology to support current and future global health research. Glass noted that cellphones can now be used to access Medline, to examine cells with a lens-free microscope attachment, measure activity and diet, and monitor adherence to anti-retroviral treatment. “New technology is game changing” in health research, Glass said.

Fogarty has recently partnered with the Fulbright program to establish a Fogarty-Fulbright Fellowship in Public Health to promote the expansion of research in public health and clinical research in resource-limited settings. The first four fellows were selected in July 2011 to work in three countries, and FIC hopes to extend to 16 countries in the coming year.

Glass noted that an increasing number of NIH institutes and centers are supporting global health programs and activities. Global health is no longer contained within NIAID, NCI, and the Office of AIDS Research. Similarly, FIC is supporting not only projects that are based in traditional health areas, but also innovative programs that involve law, ethics, economics, engineering, decision making, anthropology, and a range of social sciences. He pointed to the FIC Framework Programs for Global Health Innovation as an example (http://www.fic.nih.gov/programs/pages/framework-innovations.aspx).

The FIC strategy will continue to focus on non-communicable diseases, implementation science, building and supporting new partnerships, maintaining core emphasis on training for research, and supporting the efforts of NIH in global health. Glass also appended global mental health to the list of strategic directions. He called on universities to encourage electives and rotations in developing countries for students and residents, build partnerships and twinning relationships, and address health disparities at home and abroad (engaging what he called the “glocal” community).

Glass concluded his talk by stressing that supporting global health efforts is good for science, diplomacy, humanity, business and competition, good for the war on terrorism, and good for our own future. In short, he said, it’s the right thing to do. “These are wonderful times,” he said, “and we have to take advantage of it while we have it.”

Dr. Julio Frenk, Dean of the Harvard School of Public Health and co-chair of the initiative that produced the report, introduced the Commission’s work and positioned the resultant report in the context of historical trends in both instructional and institutional development over the past 100 years. With the publication of the landmark Flexner Report in 1910, the instructional focus of medical education shifted to basic and clinical sciences, and the university became the institutional home for medical education. Beginning in the 1970s, the instructional focus shifted to a problem-based curriculum, as academic medical centers were established to provide the institutional foundation for problem-based medical education and research.

The Lancet Commission report espouses the importance of a competency based curriculum that integrates education systems with health systems, on a local, national, regional and global level. Frenk explained that in the new model, “populations,” who previously may have been viewed as clients or consumers of a health system, are now seen as fundamental stakeholders and contributors to the design of an integrated education and health system that addresses real needs in the workforce. To date, systemic failures in the education of health professions have produced a “fundamental mismatch of competencies to needs” leading to an excess of “doctors without jobs and jobs without doctors.”

The Commission report, which has been formally launched in 20 locations worldwide and has been translated into 6 languages, articulates 10 specific recommendations for instructional and institutional reform that links education and health systems. The desired result is an integrated system that produces change agents trained to address real local and global health needs.

David Serwadda

Dr. David Serwadda, Professor of Public Health at Makerere University, presented on the distribution and reception of the Commission report in Uganda and its relevance to the Sub-Saharan Africa context. Serwadda predicted that by 2050, 1/5 of the global population will live in Africa, noting that Africa will see “a refugee situation in slow motion” as huge portions of the population migrate from rural to urban areas, resulting in 60% of Africa predicted to be urbanized by 2050. Serwadda observed that, meanwhile, there is a “huge hemorrhage of physicians from Sub-Saharan Africa” to higher-income regions of the world (regions that Dr. Frenk cleverly referred to as the “undeveloping world”).

“Many of the recommendations in this report have been going on at Makerere for many years,” Serwadda said. “The report resonates with what some of these institutions have already been doing and it reinforces that this is something right for us to move forward.”

Zulfiqar A. Bhutta

Dr Zulfiqar A. Bhutta, Chair of Division of Women and Child Health at Aga Khan University, presented the state of health education in Pakistan and summarized the activities related to the Lancet report. Challenges to the training and maintenance of a health workforce in Pakistan include the fact that most medical colleges are in urban centers and that of approximately 6200 physicians trained each year, about 1700 are “lost” due to emigration or decisions not to enter the workforce, namely that many of the female graduates go on to raise families instead of practice medicine.

In the late 2000s, Prime Minister Benazir Bhutto implemented the largest community health worker program in the region which positioned lady health workers as the backbone of community health services. Pakistan now has a health system that bulges with physicians, albeit poorly distributed, and with well-trained lady health workers but with few other intermediary cadres of health workers. The government is focusing its attention on task shifting and on care in rural areas.

The Lancet report has been distributed and discussed widely in Pakistan, in both formal and informal settings, by the leaders of 26 medical schools, universities and postgraduate colleges, with many having discovered and read the report on their own prior to having been invited to discuss it at a national level.

The leaders expressed “intense interest and broad agreement with the report” and identified primary challenges to its successful implementation – lack of resources (faculty, financial, transportation), a “dysfunctional health system,” and clarity and relevance of the competency requirements which address local and global or regional needs. They developed specific action points to address each of the identified challenges.

And then, in June 2010, the Pakistan Ministry of Health was abolished, as curtly noted here: http://www.health.gov.pk/. As a result, all health planning was shifted to the district and provincial levels, which are now embarking on the same planning and analysis that was already conducted at the national level.

Uganda and Pakistan provide enlightening case studies of the potential impact of the Lancet Commission report, as well as acute examples of the challenges involved in implementing its recommendations.

During the lunch hour on Sunday, students, faculty, and other conference participants had the opportunity to discuss a topic that is fundamental to global health work and research, but often not discussed: Sex and Gender.

We broke up across four tables and three themes to discuss how to think about theoretical approaches to sex and gender; empirical methods for researching them; and how to get the word out about the importance of understanding the impacts and implications of sex and gender (knowledge transfer). One of the important questions that came up in the in terms of theoretical approach was whether we need to study gender in global health, or if we need to mainstream gender (and understand the implications) in global health. The answer, which received wide agreement, was that we need both.

There was also a valuable discussion about the critical nature of understanding a local context before making assumptions about how gender and sex influence life in that environment, and the need for local conceptualisations of gender and feminism to inform our work. It is imperative that we incorporate sex and gender in our work, many agreed, but we must be careful not to perpetuate imperial assumptions of what is ‘best’ for men and women.

The importance of engaging men and understanding masculinity in our pursuit of promoting gender equality was raised in a few groups. Discussions around empirical methods brought up the challenges of asking people to tick potentially overly simplistic male/female boxes in our data gathering, as well as the importance of doing both quantitative and qualitative research in order to truly understand the complex dynamics of sex and gender that impact daily life in all parts of the world.

We then finished up with a discussion of knowledge transfer, which raised some great points about how gender is not traditionally given its due place in global health and medical curricula. We need to advocate for greater incorporation of sex and gender on our various campuses and highlight its value in global, public health and medicine, not just because many people are interested in it, but because the impact and implications of sex and gender are integral to improving the health and well being of men, women, and children.